This article is more than 5 years old. Information may no longer be current.
HT use in asymptomatic women up for discussion
Click Here to Manage Email Alerts
22nd Annual Meeting of NAMS
WASHINGTON, D.C. — During an academic debate held here, two physicians argued the issue of whether the use of hormone therapy is ever warranted in asymptomatic postmenopausal women.
David F. Archer, MD, professor of obstetrics and gynecology, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, took the “pro” side, arguing that menopause is an endocrinopathy. He pointed out that, as women age, ovarian function declines, follicle-stimulating hormone levels rise and other changes occur.
“If we measured a woman’s thyroid-stimulating hormone and it was elevated and her thyroxine level was falling, we would assume that this woman has hypothyroidism and we would have no qualms treating it, even though only 12% of women have clinical hypothyroidism. On the other hand, menopause affects 100% of women globally.”
Archer also explained that some human and rodent data suggest that estrogen retards the development of atherosclerosis, has a slightly beneficial effect on lipid profiles and, most importantly for an aging woman, helps maintain vascular reactivity. In addition, estrogen has positive ramifications for bone endpoints. Evidence shows that bone mineral density rapidly increases with estrogen use and rapidly decreases after discontinuation of treatment. Moreover, therapy has been shown to reduce fracture risk, he said, and even among asymptomatic women has the potential to boost muscle strength when added to an exercise regime. Subtle improvements in quality of life, such as increased libido, are also significant.
Archer acknowledged the potential adverse effects of estrogen use as well. He noted, however, that the link to venous thromboembolism associated with HT disappears after 2 years. The risk for neoplasia is also slight, he said. Data from the Women’s Health Initiative (WHI) and Women’s Health Study conflict as to the relationship between duration of use and development of neoplastic breast cells.
In response, James A. Simon, MD, clinical professor at George Washington University School of Medicine and medical director of Women’s Health & Research Consultants, said data from the WHI and other randomized clinical trials denote considerable increases in incidence of stroke and pulmonary embolism with estrogen therapy, as well as higher risk for venous thromboembolism with HT.
Simon pointed out that information from the WHI does not indicate benefit for prevention of cardiovascular disease, and maintenance of vascular reactivity is only evident if a woman has healthy arterial vessels (i.e. coronary arteries). Moreover, physicians cannot reliably identify women at risk for coronary artery disease and therefore cannot determine whether HT will be helpful for certain patients. In terms of bone density, Simon agreed that estrogen can increase BMD and may reduce the risk for fracture, but he cited other treatments, such as fluoride, increase BMD but subsequently were found to increase fracture risk. Furthermore, he noted that WHO lists estrogen as a carcinogen.
He recommended that physicians “be careful about recommending any treatment for every asymptomatic woman. For primary prevention, we should instead recommend exercise, stress and weight reduction or some other interventions that have been documented to be beneficial, such as statins or aspirin.”
After the presentations, the audience favored pro argument by a narrow margin of 52% to 48%.
For more information:
- Goldstein SR. Debate — Is there ever an indication for hormone therapy in an asymptomatic postmenopausal woman? Presented at: the 22nd Annual Meeting of the North American Menopause Society; Sept. 21-24, 2011; Washington, D.C.
Disclosure: Dr. Archer is an advisory board member of, consultant/speaker for or has received research grants from Bayer, Chemo, Corcept, Merck, Pfizer, Warner Chilcott, Watson and Duramed/Barr. Dr. Simon is an advisory board member of, consultant/speaker for or has received research grants from Abbott, Agile, Amgen, Ascend, Azur, BioSante, Boehringer Ingelheim, Depomed, Fabre-Kramer, Laboratoire HRA Pharma, Meditrina, Merck, Merrion, NDA Partners, Novo Nordisk, Novogyne, Pfizer, Shionogi, Slate, Teva, Trovis, Warner Chilcott, Watson, EndoCeutics, Palatin Technologies and Bayer.
We've been having a very exciting meeting this year at the 22nd Annual Meeting of the North American Menopause Society in Washington, D.C., and perhaps one of the most fun sessions was a debate between two very talented speakers - Dr. David Archer and Dr. James Simon - on the controversial topic of whether there is ever a reason to use hormone therapy in the asymptomatic woman. We know that the indications that the FDA has given us are for treating symptomatic women, so these two men were given the challenge of debating the pro or the con side. They did not know before they arrived to which side they would be assigned. So they put out their best efforts, and in the end, it was pretty close to a tie as to whether or not we should consider giving women without symptoms treatment or not. One could make an argument for using HT in the asymptomatic woman, and a perfect case would be to prevent significant bone loss for someone at high risk for osteoporosis but is not symptomatic at the time. Another less well-proven area would be to prevent vaginal atrophy in a person who is headed in that direction. So there are some caveats like that to HT and we'll just have to stay tuned about how well they're received.
– Margery Gass, MD, NCMP
Executive Director of the North American Menopause Society
Consultant, Cleveland Clinic
Disclosure:Dr. Gass reports no relevant financial disclosures.
 |
Follow EndocrineToday.com on Twitter. |